04090218CITY OF CUPERTINO
'UR TRNFU�RMAT�QN
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090218
M
PERMIT ISSUE DATE
DE: CUPERTINO HGUSING PARTNERS
13139999SANITARY
OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I homey a. Iain 1 Am limned uMcr provisions of CAapmr 9 (commencing
wish Section 700) of Division 3 ofdc Buainw end ProfeeWns Code, and my license is
InmBformendefree" 3Rek
LIMA. Cl . Lk.1$
NEW CONDO - 1320 SQ: FT.
Dem Contractor JP4 gsA_
A CHITECrS DECLARATION
I car derrtand my plc I used as public mends
Licensed Pmfcuinm
N ILDER DECLARATION
affi I em exempt from the Cnannor's License Lew for the
I herebyexempt
following moon.(Sc un and PnNcWuns Code: Any city of county
which requires a Permit to construct, altar. Improve, demolish, or repair Any structure
prior at its issuance. also requires he Applicant for such Permit to file asigoed statement
Sq. Ft. Floor Area
Valuation
that he is licensed Panama se IN provisions of the Comncrees 1-4ense I..w(Cho,ler9
(commencing with Section 7000) M Division 3 of the Business and Professions Cade) or
that K 4 exempt therefrom And the basis for the alleged exemptive. Any violation of
APN Number
Occupancy pe
Section 7031.5 by any applicator for a permit subjects the applicant 10 A civil Penalty of
not more than an hundred dollars ($500).
❑ I, As owner of the Properly. or my employees with wages as their sole compensation,
31620084.00 Required Inspections
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will do the work and thwroxwe ls not intended a offered for sale(Sec. 704/, Business
and Profession COCA: The Cantacserk License Lew does ant apply se an owner of
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property who buildsartmpoves demon, and whodom such work himselfor through his
own employees, provided that such Improvements we not Intended oroaered for sale. If,
however, the building or improvement is sold within one you of compledon, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
tile.).
❑ 1. as owner of she Property, am exclusively Contacting with licensed contractors to
consumer the pmkn (Sec. 7044. Business and Professions Code:) The Contractor's U.
cave law drum not apply to an owner of property who builds or improves tieleve, and,
who contracts for such projects with a cormater(s) licensed pursuant to the Guarantees
Lkcnac Lew.
❑ 1 am exempt antler See. , B k P C fm this moon
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 hereby &Man under penalty of perjury am of the following declarations:
have and will maintain a Certificate of Consent to ulf4mum for Worke'sCmnpn-
sation, u provided for by Section 3100 of the Labor Code, for the performance of the
work for which this permit is issued.
'
❑ 1 have And will maintain Worker's Compensation Insurance, u required by Section
3700 of the Labor Cede, far the performance of the work for which this Permit is issued.
My War ace/, buffam a canner and Policy number Am:
�Co.mape(n-sative
Cartier.'AL-Imao'.Si .f hGPoIIty No.:C2Gi'.ka�.2Jv✓
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CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(phis section used Out bf Completed If the permit is forest, hundreddollam (SIM)
or lass.)
I certify that In the performance of the work for which this permit Is Issued, I shall not
employ any person In any manner Bo as In become subject to the Workers' Compensation
Lows of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the LAW Code, you must
forthwith Comply with such movisine, or this permit shall be domed mated.
CONSTRUCTION LENDING AGENCY
1 hereby aRnm that dram 4 a construction lending agenry, farthe performance of
the wash fru which this permit is issued (Sce 3097, Civ. C.)
Lendoes Name
Lender'. Address
I certify that 1 have read this application end sum that the shove Information its
correct. 1 agree to comply with all city and county ordinances and Blom lam MIMIng b
building convection, and hereby induction Mprommatives of this city to enter upon the
above-mantiuned property for Inspection pure ICL
(We) agree to ave, Indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may In any my acerae against mid City
In consequence of the grunting of Nis peonit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATION -
a -roofs
Type of Roof
'0
Signema of m Dam
HAZARDOUS MATERIALS DISCLOSURE
Will de applicant or future building occupant atom ruhandle hamadous material
as defined by the Cupenloo Municipal Code. Chapter 9.11, and the Health and Safely
Codec, Section 15533(.)7
All roofs shall be inspected prior to any roofing material being installed.
Yaa
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building oreupanl ata eyulPmenI or devices which
hamrdaux air contaminants a defined by the Bay Art. Air Quellly Management
all new materials for inspection.
nricl7
❑Yv
I have read the hamrMus materials r udecmen4underChapter6,95oftheColifv-
meHalth As SARtyCode. Sectios, 25503.25533 And 25534.1 malformed the ifthe building
does of currently haw a mnanL that It 4 my responsibility to notify the oc upant of tht,
nquimmems whjc�kfust he mel prior Or issuance ofa CCMRcam of Occupancy.
Sig nature of Applicant Date
.
u
All roof coverings to be Class "B" or better
Oworo .t ages D